HOLIDAY FUN PROJECT FOR 5-10 YEAR OLDS

CIRCLE HOUSING LEAF PHIPPS BRIDGE AND CHERRY TREES HOSTED BY SOUTH MITCHAM COMMUNITY ASSOICATION

PLEASE DROP THIS FORM OFF AT SOUTH MITCHAM COMMUNITY CENTRE BY 2PM ON WEDNESDAY MARCH 30TH

Personal Information

Child/Young Person Full Name:

Preferred Name (if different): / Parent/Carer Full Name:

Home Address

and Parent/Carer Contact Telephone Number/s / Post Code: Telephone Number:-
Mobile No.:-
Email:
Date of Birth / / / /

Age

/

Male

( ✔) / /

Female

( ✔) /
Other persons who can be reached in case of emergency. /

Name:

TEL: /

Name:

TEL:

Additional Information

GP’s Name Address &
Tel. Number / Post Code: Telephone Number:

Please tell us about:

·  Any Dietary requirements

·  Medication taken regularly

·  Special Educational Needs

·  Any other relevant information

/
All Saints Centre accepts no responsibility for

Loss or damage to personal possessions

Ethnic Origin (Please Tick One Box Only)
Asian or Asian British / Mixed Heritage / White / Black or Black British
Bangladeshi / White & Black Caribbean / British / Caribbean
Indian / White & Black African / Irish / African
Pakistani / White & Asian / European / Black Other
Chinese / Other Mixed Heritage / White Other
Asian Other
Other Ethnic Group
(Please State) / Not Known/Prefer Not To Say

Data Protection Statement: In accordance with the Data Protection Act 1998 personal information given will remain confidential and only be used for the purpose of this project. Information collected will be held by South Mitcham Community Association and Personal Independence CIC and will be shared with funders Circle Housing Merton Priory as part of the project evaluation.

Please tick box if you do not want this to be shared q

HOLIDAY FUN PROJECT FOR 5-10 YEAR OLDS

CIRCLE HOUSING LEAF PHIPPS BRIDGE AND CHERRY TREES HOSTED BY SOUTH MITCHAM COMMUNITY ASSOICATION

PARENT/CARER AGREEMENT

Please tick the 2 activities you would like your child to attend?

April 5th / April 7th
Dance/Drama / Circus Skills
Art / Steel Pans
**Acacia Adventure Playground Outing (Wednesday April 6th)
An Acacia Adventure Playground registration form must also be completed in addition to this Holiday Fun form / Please state an additional choice that may be used if your preferred selection is fully booked:

·  I give consent for my child to appear in photos and video/digital recordings of the activities that will be used by Circle Housing Merton Priory, Personal Independence CIC, South Mitcham Community Association, Uptown UK, Inner World Arts and Merton Voluntary Service Council. The images will only be used to publicise the work of the organisations stated (i.e., website, funding reports, funding bids) and may be shared with partner agencies. If you have any objections please inform the Holiday Fun staff member on the day.

·  **I give consent for my child to be escorted by staff to the Acacia Adventure Playground (journey will include walking and using public transport). If the Acacia Adventure Playground registration form is not completed I accept that my child cannot go on the trip ( the form can be collected from South Mitcham Community Centre or downloaded from www.merton.gov.uk/adventure-playground-acacia.htm)

·  I understand that if project staff have any concerns in regards to the safety and welfare of my child then safeguarding procedures will be followed.

Full Name of Child:

Parent/Carer Name:

Signed: (Parent/Carer) Date: